Adeel, Waqas, MD

Brewster, Nathan, DO

Holahan, Brian J, DO

Kears, Alaynna C, DO

Kloska, Michal, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine Pleural Effusion With Trapped Lung Associated With Methimazole Induced Hypothyroidism Nathan Brewster DO Lehigh Valley Health Network, Nathan.Brewster@lvhn.org Michal Kloska MD Lehigh Valley Health Network, Michal.Kloska@lvhn.org Alaynna C. Kears DO Lehigh Valley Health Network, Alaynna.Kears2@lvhn.org Brian J. Holahan DO Lehigh Valley Health Network, Brian.Holahan@lvhn.org Waqas Adeel MD Lehigh Valley Health Network, Waqas.Adeel@lvhn.org Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine  Part of the Internal Medicine Commons Published In/Presented At Brewster, N. Kloska, M. Kears, A. Holahan, B. Adeel, W. (2019, October). Pleural Effusion With Trapped Lung Associated With Methimazole Induced Hypothyroidism. Poster Presented at: CHEST Annual Meeting, New Orleans, LA. This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. © 2019 Lehigh Valley Health NetworkLVHN.orgPleural Effusion With Trapped Lung Associated With Methimazole Induced HypothyroidismNathan Brewster, DO, Michal Kloska, MD, Alaynna Kears, DO, Brian Holahan, DO, Waqas Adeel, MDDepartment of Internal Medicine, Lehigh Valley Health Network, Allentown, Pa.IntroductionAnti-thyroid medications can cause a variety of adverse reactions. There are only a small amount of reported cases associating the thioamides with pleural effusions.1,2,3 None  of these were associated with trapped  lung. We present a case of a trapped  lung with unclear etiology associated  with methimazole and hypothyroidism. Case presentationA 36-year-old male with a history of type 1 diabetes and Grave’s disease status post radio-iodine ablation on methimazole presented to the hospital after one month of shortness of breath and cough with no associated fevers, chills, or night sweats. The patient was found to have a large right pleural effusion with mediastinal shift to the left with a completely collapsed lung. He subsequently had a chest tube placed with four liters fluid drained. Pleural fluid showed an exudative effusion by Light’s Criteria with fluid and serum protein of 4.6 g/dL and  8.6 g/dL respectively. Fluid and protein lactate dehydrogenase (LDH) were 120 U/L and 320 U/L respectively. Pleural glucose Due to concern for trapped lung, the patient under went a video-assisted thorascopic surgery converted to thoracotomy for decortication of the right upper, middle, and lower lobes. After decortication, the patient had increased aeration of the lung with no evidence of consolidation or mass. He was ultimately discharged home with resolution of the hypothyroidism and placed back on methimazole. He has only had recurrence of a mild asymptomatic effusion.references1 Lee JH, Park M, Park MJ, Jo YS. Massive pleural and pericardial effusion due to hypothyroidism in a patient with a surgically treated thyroid-stimulating hormone- producing pituitary adenoma. Acta Clin Belg. 2018;73(5):398-4012 Da Costa P, Silva F, Henriques J, et al. Methimazole associated eosinophilic pleural effusion: a case report. BMC Pharmacol Toxicol. 2017 Mar;18(1):163 Sen N, Ermis H, Karatasli M, Habesoglu M, Eyuboglu F. Propylthiouracil-associated eosinophilic pleural effusion: a case report. Respiration. 2007;74(6):703-5ImagesImage 1. Chest x-ray demonstrating complete opacification of the right hemithorax with tracheal deviation to the left.Image 2. CT chest demonstrating a large right pleural effusion with a collapsed right lung.Image 3. Chest x-ray with persistent opacification on the right after chest tube placement.Image 4. Chest x-ray showing improved aeration after decortication of the right lung.was 95 mg/dL and pH was 7.75. Gram stain and cultures were unremarkable. Cytology was non-diagnostic for malignancy. After drainage, the patient’s right lung remained collapsed with quickly reaccumulated effusion. Serum sedimentation rate, quantiferon gold, fluid adenosine deaminase, and fluid amylase were all negative. He was found  to be hypothyroid with a thyroid stimulating hormone level of 20.7 IU/mL and free T4  of 0.31 ng/mL and his methimazole was stopped. An autoimmune panel was negative. Discussion•  The exact etiology of the effusion with trapped lung remains unclear in this  case. Hypothyroidism may have been a contributing factor for which methimazole may also have been involved. •  Methimazole has been associated with lupus-like reactions for which pleuritis and effusion could be a possibility. •  There is no clear evidence that the effusion was from infection. Malignancy is another consideration although fluid analysis was non-diagnostic and no tumor was identified on repeat imaging. •  With this patient’s recurrent small pleural effusion, it may be beneficial for him to  have close monitoring of thyroid levels and dosing of the methimazole, especially in the setting of having already experienced a trapped lung.ConclusionMethimazole and hypothyroidism may be a cause of pleural effusion and even trapped lung. When evaluating a patient’s effusion, methimazole and possibly the other thioamides must be considered as possible culprits.

Pleural Effusion With Trapped Lung Associated With Methimazole Induced Hypothyroidism

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=2767&context=medicine

Pleural Effusion With Trapped Lung Associated With Methimazole Induced Hypothyroidism

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